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. Author manuscript; available in PMC: 2026 Mar 31.
Published in final edited form as: Aging Ment Health. 2025 Dec 16;30(4):781–791. doi: 10.1080/13607863.2025.2597963

The Association Between Personality and Depressive Symptoms among Mexicans Aged 50 and Older with Pain

Sarah Navid 1, Sirena Gutierrez 2, Joseph Saenz 3, Sadaf Arefi Milani 4,*
PMCID: PMC13035039  NIHMSID: NIHMS2152092  PMID: 41400055

Abstract

Objectives:

Older adults with pain are at risk for developing elevated depressive symptoms. Personality traits, including internal locus of control (LOC) and conscientiousness, have been associated with fewer depressive symptoms in older adults. It is unknown if LOC and conscientiousness are potential buffers of depressive symptoms among middle-aged and older Mexican adults.

Methods:

We used data from the Mexican Health and Aging Study (2015 and 2018). We included participants ages 50 years and older who reported frequent pain at both waves (n=2,274). LOC and conscientiousness were measured continuously in 2015, with higher values indicating a more internal LOC or conscientious personality. We combined depressive symptoms from 2015 and 2018 to create a 4-level depressive symptoms variable: stable low/no depression (<5/<5), recently remitted (5+/<5), recent onset (<5/5+), and recurrently high (5+/5+). We used multinomial logistic regression models to assess the association between personality and depressive symptoms.

Results:

In fully adjusted models, those with a more internal LOC had a lower risk of recurrently high depressive symptoms (RRR: 0.81, 95% CI: 0.72, 0.92, p=0.001). Those with a more conscientious personality had lower risk of recent-onset [relative risk ratio (RRR): 0.87, 95% confidence interval (CI): 0.76, 0.998, p=0.046] and recurrently high depressive symptoms (RRR: 0.87, 95% CI: 0.77, 0.97, p=0.013).

Discussion:

Among middle-aged and older adults with pain, a more internal LOC and conscientious personality was associated with a lower risk of recurrently high depressive symptoms. Interventions to modify LOC and conscientiousness may be helpful in pain management by mitigating comorbid depressive symptoms.

Keywords: Pain, Depressive Symptoms, Mexico, Personality

Objectives

Pain and depression commonly co-occur, and older adults with pain are at risk for developing elevated depressive symptoms (Chou, 2007; Gutierrez, Wong, & Milani, 2022; Tang, Meng, Hägg, Burgess, & Jiang, 2022). The biopsychosocial model of pain suggests that pain is influenced by a complex interplay of biological, psychological, and social factors, which collectively shape an individual’s subjective experience of pain (Fillingim, 2017). Depressive symptoms are one aspect of psychological factors that influence an individual’s pain experience. Shared predictors of pain and depressive symptoms include older age, being female, poor self-rated health, and limitations in activities of daily living (ADL) (Gutierrez et al., 2022).

Understanding how personality traits influence the development of depression among those with pain, particularly among older adults in low- and middle-income countries like Mexico, is crucial and serves as the primary motivator for the current study. Personality traits may provide resilience to the development of depression among older adults with pain. However, few studies have examined the effects of personality traits, including locus of control or conscientiousness, on depression among those with pain. The interactional stress model states that in the face of stressful circumstances, personality can modulate the relationship between appraisal or coping with the stressor and buffer the effects of illness (Smith, 2006). The model further elaborates that in response to stressful circumstances, coping and appraisal can influence physiologic responses contributing to the illness (Smith, 2006). However, it is not clear whether this relationship stands in the pain (stressor) and depression model (illness), as well as in the context of older adults in Mexico.

Previous research has found that locus of control and conscientiousness can have an impact on health in various populations (Friedman & Kern, 2014). Both physical and mental health can be influenced by how one perceives the causes of the events in their lives. For instance, locus of control (LOC) can be defined as when a person recognizes the outcome of their experiences as being controlled by their actions or external forces (Rotter, 1966). Those who assume that their thoughts, behaviors, or actions cause their outcomes have an internal LOC, while those who believe occurrences in their lives are due to fate or luck have an external LOC (Rotter, 1966). Prior work has found that adults with an internal LOC have fewer depressive symptoms (Asadi-Pooya, Schilling, Glosser, Tracy, & Sperling, 2007; Crisson & Keefe, 1988). Halse, Bjørkløf, Engedal, Selbæk, & Barca, 2021; Musich, Wang, Slindee, Kraemer, & Yeh, 2020; Rizza et al., 2017; Wong & Anitescu, 2017). Previous research suggests that people with external health LOC belief systems tend to rely on maladaptive pain coping strategies with low self-rated ability to decrease pain (Crisson & Keefe, 1988). Those who have examined this have found that adults aged 18 and older with chronic pain conditions and a more internal locus of control tend to have lower depressive scores (Wong & Anitescu, 2017).

Another personality trait, conscientiousness, defined as “following socially prescribed norms for impulse control, to be goal-directed, to plan and to be able to delay gratification,” is a core determinant of health (Roberts, Jackson, Fayard, Edmonds, & Meints, 2009). Individuals with lower levels of conscientiousness tend to report poorer health (Atherton, Robins, Rentfrow, & Lamb, 2014; Friedman & Kern, 2014; Ibrahim, Weber, Courvoisier, & Genevay, 2020; Seto et al., 2019) and more pain (Bucourt et al, 2017). A recent study of older community-dwelling older adults (Judge, Meyr, & Segerstrom, 2024) found that those with higher levels of conscientiousness reported lower levels of pain interference with daily activities, regardless of the intensity of pain, potentially due to conscientiousness being related to better health management including regularly seeing a doctor, managing health conditions that cause pain, and better adherence to medications.

Mexico, a low-middle-income country, provides an interesting context to study depression and the role of personality traits in older adults with pain. Older Mexican adults experience a high prevalence of pain partly due to a greater exposure to certain factors associated with pain (i.e., manual labor), yet it is often undertreated (Angel, Vega, & López-Ortega, 2016; Knaul, 2021). Depression assessed using the Geriatric Depression Scale estimates that one of every eight older adults in Mexico experiences major depressive symptoms (García-Peña et al., 2008), which is also less likely to be treated in Mexico than in high-income settings (Guerra et al., 2009). One study examining community-dwelling older adults in Mexico found baseline pain to be associated with higher odds of incident elevated depressive symptoms (Gutierrez et al., 2022). However, to our knowledge, there have been no studies that have assessed how personality traits, which may matter more in the context of low- and middle-income countries, relate with depressive symptoms in individuals with pain that is often undertreated.

Our objective is to examine the effect of personality (LOC and conscientiousness) on depressive symptoms among participants aged 50 and older with pain, using the Mexican Health and Aging Study (MHAS). We hypothesize that individuals with pain and with a more external LOC and less conscientious personality will experience increased depressive symptoms and a higher likelihood of experiencing persistent depression compared to individuals with a more internal LOC and more conscientious personality.

Methods

Data

Data came from the 2015 and 2018 waves of MHAS, a national longitudinal cohort of adults aged 50 years and older in Mexico (Wong, Michaels-Obregon, & Palloni, 2017). The first wave of the study was conducted in 2001, with follow-up interviews in 2003 (Wave 2), 2012 (Wave 3), 2015 (Wave 4), 2018 (Wave 5), and 2021 (Wave 6). We used 2015 as our baseline because this is the first wave in which locus of control and conscientiousness were assessed simultaneously. The 2021 wave of MHAS was not used because of the potential effects the COVID-19 pandemic may have had on both personality characteristics and the development of depressive symptoms. Refresher samples were added in 2012 and 2018, comprising of additional cohorts of adults born between 1952-1962 and 1963-1968, respectively to maintain representation of the age 50+ population. The MHAS has a high follow-up rate for all waves, ranging from 85%–93% (Orozco-Rocha, Wong, & Obregón, 2018). Interviews elicit a wide range of information, including sociodemographic characteristics, health, disability, family background, social support, and economic well-being. The MHAS study protocol and instruments were approved by the Institutional Review Board or Ethics Committee of the University of Texas Medical Branch, the Instituto Nacional de Estadística y Geografía in Mexico, and the Instituto Nacional de Salud Pública in Mexico. The MHAS data is publicly available at MHASweb.org.

Figure 1 shows the analytical sample selection. We analyzed a cross-sectional 2015 sample and a sample of those observed in 2015 and 2018. We conducted the analysis both cross-sectionally and longitudinally to assess the impacts of acute pain versus more persistent pain. We only included data from direct interviews with participants, as pain is not assessed in proxy interviews. Because we were interested in how pain is experienced and managed within a context lacking robust health care infrastructure, we included only those who reported frequent pain, identified as those who responded yes to the question “Do you often suffer from pain?”. Including individuals without pain would have introduced substantial between-group variation that may be attributable to pain status itself, potentially obscuring the within-pain associations we sought to isolate. We tested the interaction between pain and each personality factor and found evidence of a significant multiplicative interaction between pain and conscientiousness (p=0.002) but not pain and locus of control (p=0.508). This provides evidence that conscientiousness is associated with depression in statistically distinct ways among individuals with and without pain, we focused our analyses on the subgroup with pain to better characterize this relationship. Lastly, we excluded participants missing information on depression or covariates of interest in 2015. Our cross-sectional analytical sample was 4,635. For our longitudinal sample, we included those with pain in 2015 and 2018 and with complete information on depression in 2018. Our final longitudinal sample was 2,274 participants. Those who were only included in the cross-sectional sample were on average older, more often male, and had less severe pain and chronic conditions compared to those included in both samples (Supplemental Table 1).

Figure 1:

Figure 1:

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Analytical sample selection.

Measures

Dependent variable

Self-reported depressive symptoms were measured using a modified version of the Center for Epidemiologic Studies Depression (CES-D) Scale (Radloff, 1977) at each wave of the MHAS (2015 Cronbach’s alpha=0.811; 2018 Cronbach’s alpha=0.803). Participants were asked if they experienced any of the following symptoms a majority of the time in the past week: feeling depressed, everything was an effort, sleep was restless, happy (reverse coded), lonely, enjoyed life (reverse coded), sad, tired, or that they had a lot of energy (reverse coded). Participants were classified as having elevated depressive symptoms if they endorsed five or more depressive symptoms. This cutoff has previously been validated among a clinical sample of older Mexican adults (Aguilar-Navarro, Fuentes-Cantú, Avila-Funes, & García-Mayo, 2007).

In the longitudinal sample, we used this depressive symptom classification in 2015 and 2018 to create a 4-level depressive symptoms variable. The depressive symptoms variable was categorized as: stable low/no depression, recently remitted depression, recent onset depression, and stable high depression. Previous work using the MHAS has utilized similar depressive symptoms categorizations (Meza et al., 2020; Saenz, Garcia, & Downer, 2018).

Independent variables

LOC and conscientiousness were the two personality traits assessed in the MHAS. LOC was assessed using items adapted from Rotter’s LOC Scale (Rotter, 1966; Cronbach’s alpha=0.678). Participants were asked if they agree (3 points), somewhat agree (2 points), somewhat disagree (1 point), or disagree (0 points) with a series of eight statements. The following statements reflect an internal LOC: “one is responsible for one’s own successes”, “one can do almost anything one puts their mind to”, “one’s misfortunes are the result of one’s own mistakes”, and “one is responsible for one’s own failures.” The following statements reflect an external LOC and were reverse coded: “there’s no sense in planning a lot for the future”, “the good things that happen to one are mostly due to good luck”, “most of one’s problems are due to bad luck”, “one has little control over the bad things that happen to him/her”. Scores were summed and z-score standardized to a mean of zero and a variance of one. Higher values reflect a more internal LOC, while lower values reflect a more external LOC.

Conscientiousness was measured using six items (Cronbach’s alpha=0.681) using items from the Midlife Development Inventory (Lachman & Weaver, 1997) and the International Personality Item Pool (Goldberg et al., 2006). Respondents were asked if they are organized, responsible, dedicated/hardworking, careless (reverse coded), thorough, or disciplined, with a lot (3 points), some (2 points), little (1 point), or not at all (0 points) as response options. Scores were summed and z-score standardized to a mean of zero and a variance of one. Higher values represent a more conscientious personality, while lower scores represent a less conscientious personality.

Covariates

Covariates included age (continuous), sex (male, female), years of education (continuous), marital status (married, not married), self-rated health (excellent/very good/ good, fair/poor), locality size (rural, urban), health insurance (no, yes), consumer durables as a measure of economic well-being (0-3, 4-6, 7+), social support (no, yes), pain severity (mild, moderate, severe), pain limiting activities (no, yes) chronic conditions (0,1, 2+), activities of daily living (ADL) limitations (0, 1+), instrumental activities of daily living (IADL) limitations (0, 1+). Pain severity was assessed by asking participants, “How is the pain the majority of the time?”. Pain interference with daily activities was assessed by asking participants, “Does this pain limit your usual activities such as household chores or your job?”. Chronic conditions included self-reported diabetes, arthritis, cancer, hypertension, stroke, heart attack, and lung disease. Participants were asked if a doctor had told them they had each health condition.

Analysis

We used chi-square tests of independence and t-tests to evaluate differences in baseline sociodemographic and health characteristics by elevated depressive symptoms status among respondents with pain in 2015. We used logistic regression models to assess the association between personality traits and elevated depressive symptoms among participants with pain in 2015, controlling for the covariates listed above. In sensitivity analyses, we used linear regression models to test the association between personality traits and continuous depressive symptoms. Then, among those with pain in 2015 and 2018, we used multinomial logistic regressions to test the association between personality traits in 2015 and changes in depressive symptoms from 2015 to 2018. We used generalized estimation equations to conduct a sensitivity analysis testing the association between personality traits and continuous depressive symptoms. For all longitudinal analyses, we used stabilized inverse probability of attrition weights to account for loss to follow-up, mortality, and attrition over the three-year follow-up. Weights were calculated based on the likelihood of a participant surviving and remaining in the study, conditional on sociodemographic and health characteristics. They were stabilized for baseline age, sex, and years of education (Cole & Hernan, 2008). We also tested whether locus of control and conscientiousness were nonlinearly associated with depressive symptoms by testing quadratic terms for both. We also tested moderation by age and sex. However, these were not significant and did not alter the interpretation of main effect estimates and were not included in final models. Stata 17.0 was used for all analyses.

Results

Cross-sectional sample

Overall, in 2015, 38.0% of participants reported experiencing pain; conversely, 30.4% of participants reported elevated depressive symptomatology (Figure 1). Of which, 47.6% of participants with pain (n=4,632) also reported elevated depressive symptoms, compared to 20.2% of participants who did not report pain (Cohen’s d=−0.66, p<0.001). Table 1 shows the characteristics of our cross-sectional sample by depressive symptom status. Those with elevated depressive symptoms had a more external LOC (Cohen’s d= 0.302, p<0.001) and less conscientious personality (Cohen’s d=0.159, p<0.001). Those with elevated depressive symptoms were older, were more often women, and lived in rural areas, but were less likely to be married, had fewer years of education, and had fewer consumer durables compared to those with no/low depressive symptoms. Lastly, those with elevated depressive symptoms also more often reported severe pain, pain interference, and multimorbidity compared to those with no/low depressive symptoms.

Table 1:

Baseline characteristics of the cross-sectional sample among participants (aged 50+) of the Mexican Health and Aging Study with pain in 2015 (n=4,632).

Elevated Depressive Symptoms in 2015
2015 Characteristic No Yes P-values Effect Size
(n=2,429; 52.4%) (n=2,203; 47.6%)
n (%) n (%)
Personality Traits
Locus of Control, mean (SD) 17.5 (3.6) 16.5 (3.5) <0.001 0.302
Standardized Locus of Control, median (IQR) 0.19 (−0.63, 1.00) −0.36 (−0.90, 0.46) <0.001 0.302
Conscientiousness, mean (SD) 14.0 (2.9) 13.5 (3.2) <0.001 0.159
Standardized Conscientiousness, median (IQR) 0.02 (−0.63, 0.67) 0.02 (−0.96, 0.67) <0.001 0.159
Demographics
Age, mean (SD) 66.3 (9.1) 67.7 (9.7) <0.001 −0.147
Sex <0.001 0.134
Men 968 (39.9%) 598 (27.1%)
Women 1,461 (60.1%) 1,605 (72.9%)
Years of education, mean (SD) 5.8 (4.5) 4.5 (3.9) <0.001 0.318
Marital Status <0.001 0.109
Single 317 (13.1%) 367 (16.7%)
Married 1,705 (70.2%) 1,329 (59.9%)
Widowed 407 (16.8%) 516 (23.4%)
Health Insurance 0.596 0.008
No 183 (7.5%) 157 (7.1%)
Yes 2,246 (92.5%) 2,046 (92.9%)
Consumer Durables <0.001 0.170
0-3 362 (14.9%) 516 (23.4%)
4-6 1,176 (48.4%) 1,198 (54.4%)
7+ 891 (36.7%) 489 (22.2%)
Locality Size <0.001 −0.054
Rural 974 (40.1%) 1,000 (45.4%)
Urban 1,455 (59.9%) 1,203 (54.6%)
Health Characteristics
Pain Severity <0.001 0.171
Mild 927 (38.2%) 573 (26.0%)
Moderate 1,065 (43.8%) 944 (42.9%)
Severe 437 (18.0%) 686 (31.1%)
Pain Interferes with Daily Activities <0.001 −0.221
No 1,514 (62.3%) 886 (40.2%)
Yes 915 (37.7%) 1,317 (59.8%)
Chronic Conditions <0.001 0.145
0 714 (29.4%) 435 (19.7%)
1 899 (37.0%) 738 (33.5%)
2 or more 816 (33.6%) 1,030 (46.8%)
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Note. Some percentages may not sum exactly to 100.0% because of rounding. Effect sizes display Cohen’s d for continuous variables and Cramer’s V for categorical variables. IQR: Interquartile range; SD: standard deviation.

Table 2 displays the results from our logistic regression models examining the association between personality traits and elevated depressive symptoms in 2015. In fully adjusted models, a more internal LOC (OR: 0.83, 95% CI: 0.78, 0.89, p<0.001) was associated with elevated depressive symptoms compared to those with an external LOC. A more conscientious personality was associated with elevated depressive symptoms (OR: 0.92, 95% CI: 0.86, 0.98, p<0.001), compared to those with a less conscientious personality. We see similar findings in sensitivity analysis examining continuous depressive symptoms, where those with a more internal LOC and conscientious personality had fewer depressive symptoms compared to those with a more external or less conscientious personality (Supplemental Table 2).

Table 2:

Odds ratios and 95% confidence intervals for the association between personality in 2015 (locus of control and conscientiousness) and elevated depressive symptoms in 2015 (ref: no/low depressive symptoms) among participants (aged 50+) of the Mexican Health and Aging Study with pain in 2015 (n=4,632).

Model 1 Model 2 Model 3
2015 Characteristics OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value
Personality Traits
Locus of Control 0.75 (0.70, 0.80) <0.001 0.83 (0.78, 0.89) <0.001 0.83 (0.78, 0.89) <0.001
Conscientiousness 0.90 (0.84, 0.95) <0.001 0.91 (0.86, 0.97) 0.004 0.92 (0.86, 0.98) 0.008
Demographic Characteristics
Age 1.01 (1.00, 1.01) 0.085 1.00 (0.99, 1.01) 0.790
Sex
Men ref. ref.
Women 1.78 (1.55, 2.04) <0.001 1.56 (1.35, 1.79) <0.001
Years of Education 0.97 (0.95, 0.99) <0.001 0.97 (0.95, 0.99) 0.001
Marital Status
Single ref. ref.
Married 0.76 (0.64, 0.91) 0.002 0.73 (0.61, 0.88) 0.001
Widowed 0.91 (0.73, 1.12) 0.357 0.89 (0.71, 1.11) 0.293
Health Insurance
No ref. ref.
Yes 1.09 (0.87, 1.38) 0.456 1.04 (0.82, 1.32) 0.768
Consumer Durables
0-3 ref. ref.
4-6 0.81 (0.69, 0.96) 0.013 0.80 (0.67, 0.95) 0.011
7+ 0.52 (0.42, 0.63) <0.001 0.52 (0.42, 0.64) <0.001
Locality Size
Rural ref. ref.
Urban 1.02 (0.90, 1.16) 0.763 0.99 (0.87, 1.14) 0.920
Health Characteristics
Pain Severity
Mild ref.
Moderate 1.24 (1.08, 1.44) 0.003
Severe 1.78 (1.49, 2.11) <0.001
Pain Interferes with Daily Activities
No ref.
Yes 1.93 (1.70, 2.21) <0.001
Chronic Conditions
0 ref.
1 1.20 (1.02, 1.42) 0.026
2 or more 1.62 (1.39, 1.91) <0.001
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Note. Model 1 Pseudo R2= 0. 0183; Model 2 Pseudo R2 =0.0516; Model 3 Pseudo R2=0.0930. CI: confidence interval; OR: odds ratio.

Longitudinal sample

In our longitudinal sample, 30.8% of participants had stable no/low depressive symptoms, 15.5% had recently remitted depressive symptoms, 17.3% had recent-onset depressive symptoms, and 36.3% had recurrently high depressive symptoms (Table 3). Table 3 displays the characteristics of this sample by their depressive symptoms status. Those with recurrently high depressive symptoms had the most external locus of control, while those with stable low/no and recent onset depressive symptoms had the most internal locus of control. Those with stable low/no depressive symptoms had the most conscientious personality.

Table 3:

Baseline characteristics of the longitudinal sample, among participants (aged 50+) of the Mexican Health and Aging Study with persistent pain (in 2015 and 2018) by changes in depressive symptom status (n=2,274).

Depressive Symptoms Status
Stable low/no Recently remitted Recent onset Recurrently high P-values Effect Size
(n=701; 30.8%) (n=353; 15.5%) (n=394; 17.3%) (n=826; 36.3%)
2015 Characteristic n (%) n (%) n (%) n (%)
Personality Traits
Locus of Control, mean (SD) 17.8 (3.6) 16.9 (3.5) 17.3 (3.6) 16.5 (3.5) 0.838 0.153
Standardized Locus of Control, median (IQR) 0.19 (−0.63, 1.00) −0.09 (−0.90, 0.46) 0.19 (−0.63, 0.73) −0.36 (−0.90, 0.46) <0.001 0.150
Conscientiousness, mean (SD) 14.2 (2.8) 13.7 (3.1) 13.8 (3.1) 13.5 (3.2) 0.004 0.094
Standardized Conscientiousness, median (IQR) 0.34 (−0.63, 0.67) 0.02 (−0.63, 0.67) 0.02 (−0.96, 0.67) 0.02 (−0.63, 0.67) 0.0011 0.078
Demographics
Age, mean (SD) 65.4 (8.5) 67.5 (9.3) 66.3 (8.8) 66.2 (8.9) 0.333 0.075
Sex <0.001 0.156
Men 265 (37,8%) 91 (25.8%) 122 (31.0%) 173 (20.9%)
Women 436 (62.2%) 262 (74.2%) 272 (69.0%) 653 (79.1%)
Years of education, mean (SD) 6.3 (4.4) 4.6 (3.9) 5.2 (4.1) 4.3 (3.7) <0.001 0.210
Marital Status <0.001 0.075
Single 78 (11.1%) 56 (15.9%) 60 (15.2%) 129 (15.6%)
Married 511 (72.9%) 215 (60.9%) 265 (67.3%) 514 (62.2%)
Widowed 112 (16.0%) 82 (23.2%) 69 (17.5%) 183 (22.2%)
Health Insurance 0.960 0.012
No 47 (6.7%) 22 (6.2%) 28 (7.1%) 53 (6.4%)
Yes 654 (93.3%) 331 (93.8%) 366 (92.9%) 733 (93.6%)
Consumer Durables <0.001 0.153
0-3 79 (11.3%) 70 (19.8%) 76 (19.3%) 209 (25.3%)
4-6 344 (49.1%) 192 (54.4%) 191 (48.5%) 463 (56.1%)
7+ 278 (39.7%) 91 (25.8%) 127 (32.2%) 154 (18.6%)
Locality Size <0.001 0.123
Rural 236 (33.7%) 160 (45.3%) 181 (45.9%) 393 (47.6%)
Urban 465 (66.3%) 193 (55.7%) 213 (54.1%) 433 (52.4%)
Health Characteristics
Pain Severity <0.001 0.224
Mild 243 (34.7%) 94 (26.6%) 124 (13.5%) 165 (20.0%)
Moderate 318 (45.4%) 165 (46.7%) 184 (46.7%) 369 (44.7%)
Severe 140 (20.0%) 94 (26.6%) 86 (21.8%) 292 (35.4%)
Pain Interferes with Daily Activities <0.001 0.099
No 422 (60.2%) 153 (43.3%) 226 (57.4%) 290 (35.1%)
Yes 279 (39.8%) 200 (56.7%) 168 (42.6%) 536 (64.9%)
Chronic Conditions <0.001 0.386
0 179 (25.5%) 78 (22.1%) 90 (22.8%) 137 (16.6%)
1 262 (37.4%) 135 (38.2%) 135 (34.3%) 255 (30.9%)
2 or more 260 (37.1%) 140 (39.7%) 169 (42.9%) 434 (52.5%)
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Note. Some percentages may not sum exactly to 100.0% because of rounding. Effect sizes display Cohen’s f for continuous variables and Cramer’s V for categorical variables. IQR: Interquartile range; SD: standard deviation

In fully adjusted models, those with a more conscientious personality had lower risk of recent-onset (RRR: 0.87, 95% CI: 0.76, 0.998, p=0.046) and recurrently high depressive symptoms (RRR: 0.87, 95% CI: 0.77, 0.97, p=0.013). Those with a more internal LOC had a lower risk of recurrently high depressive symptoms (RRR: 0.81, 95% CI: 0.72, 0.92, p=0.001). We see similar findings in sensitivity analysis examining continuous depressive symptoms, where those with a more internal LOC and conscientious personality had fewer depressive symptoms over the two waves compared to those with a more external or less conscientious personality (Supplemental Table 3).

Discussion

In a cohort of middle-aged and older adults (ages 50+) with pain in Mexico, we found that a more internal LOC and conscientious personality were associated with a lower risk of recurrently high elevated depressive symptoms in both 2015 and 2018, while a more conscientious personality was associated with a lower risk of recent onset depressive symptoms. This may suggest that middle-aged and older individuals with pain, as well as an internal LOC and conscientious personality, are less prone to experiencing depressive symptoms compared to individuals with a higher degree of external LOC and less conscientious personality.

Our findings align with existing cross-sectional literature, emphasizing that adult patients of all ages and with various medical conditions, both community-dwelling and clinical, who experienced pain, tend to have fewer depressive symptoms if they have an internal LOC (Asadi-Pooya, Schilling, Glosser, Tracy, & Sperling, 2007; Halse, Bjørkløf, Engedal, Selbæk, & Barca, 2021; Musich, Wang, Slindee, Kraemer, & Yeh, 2020; Rizza et al., 2017; Wong & Anitescu, 2017). Our study goes one step further by examining LOC in the context of Mexico, which has a rapidly aging population (Angel et al., 2016) and a high prevalence of pain (Milani, Howrey, Rodriguez, Samper-Ternent, & Wong, 2022).

Within the context of adults with chronic pain, Wong et al. (2017) evaluated associations with depressive symptomatology utilizing three distinct groups that categorized individuals based on whether their LOC was mainly characterized by an internal LOC (as outlined in our research), chance (a proxy for external LOC), or by attributing control to powerful others (Wong & Anitescu, 2017). Similar to our findings, they found variations in depression scores, specifically indicating significantly higher depression scores in the chance group compared to the internal LOC group. The study assessed LOC using the Multidimensional LOC scale and indicated the scale’s use as a future predictor for psychiatric comorbidities like depression. Rizza 20154 studied patients diagnosed with Parkinson’s disease by a general practitioner and determined that outpatient patients with more external LOC had decreased health-related quality of life (Rizza et al., 2017). This demonstrates that an external LOC can negatively impact health-related quality of life in chronic conditions, such as Parkinson’s disease, highlighting the potential for similar effects in older adults with chronic pain and depression. They also determined a more internal LOC to be negatively associated with depression.

The other studied personality factor, conscientiousness, was significantly associated with depressive symptoms. Conscientiousness is a personality trait characterized by self-discipline, organization, and goal-directed behavior (Roberts et al., 2009), and in this context, it was associated with reduced depressive symptoms in those with stable pain across both waves. Our findings are consistent with prior work among women with fibromyalgia, rheumatoid arthritis, and other rheumatologic conditions and among older adults with cancer (Bucourt et al., 2017; Krok & Baker, 2014; Seto et al., 2019), which found that conscientiousness was related to quality of life. Bucourt and colleagues reported that patients with fibromyalgia and low conscientiousness experienced increased pain, i.e., decreased quality of life (Bucourt et al., 2017). Seto and colleagues (2019) found that higher conscientiousness was also associated with improved psychological health and health-related outcomes in the context of patients, aged 21 and older, diagnosed with fibromyalgia (Seto et al., 2019). We also note that, provided depression is detected in a healthcare setting, elevated depression can be managed through effective medication use. Although both an internal LOC and a conscientious personality have been linked with better medication adherence in meta-analyses and systematic reviews (Molloy, O’Carroll, & Ferguson, 2014; Náfrádi, Nakamoto, & Schulz, 2017), the benefits of a conscientious personality may be attenuated with advancing age (Molloy et al., 2014). Future studies should evaluate the role of pain treatments and management in modifying these associations, especially in the context of Mexico, where a significant proportion of the population, particularly women, experience increasing pain trajectories over time, contributing to decreased quality of life (Milani et al., 2022). Although our study focused on pre-pandemic data to avoid potential period effects, future work should examine whether the associations observed remain robust in the years following the COVID-19 pandemic, as the widespread social, behavioral, and health disruptions during this period may have altered pain experiences, personality, and their psychological correlates (Hernández-Díaz, et al., 2022; Sutin et al, 2022).

The implications of our research extend to clinical considerations. The co-occurrence of depression and pain affects diagnosis and treatment (Bair, Robinson, Katon, & Kroenke, 2003). The presence of pain complicates the recognition of depression, while moderate to severe pain exacerbates depressive symptoms due to the shared biological pathways and neurotransmitters (serotonin and norepinephrine) between depression and pain (Bair et al., 2003). Interventions, including training and therapy, may work to modify LOC and conscientiousness, thereby influencing the perception of pain (Roberts et al., 2017; Roditi & Robinson, 2011). Psychoeducational approaches and cognitive behavioral therapy emerge as viable avenues, emphasizing the role of beliefs in shaping pain perception (Vanhaudenhuyse et al., 2018). The influence of social support, particularly in a context like Mexico with strong social networks, warrants further investigation into its impact on pain perception. The validation of an individual’s pain by family and friends has been shown to improve chronic pain outcomes, especially for individuals with an internal LOC (Lee, Green, Palmarella, McNamara, & Wachholtz, 2022). A study of over 4,000 participants found that those who experienced validation of their pain by loved ones reported less negative life impact and better chronic pain outcomes, highlighting the importance of considering both individual personality traits and the social environment in managing pain and depressive symptoms. Future research to determine the most appropriate management of pain symptoms will be instrumental in decreasing the negative impacts of pain on quality of life.

Limitations

Our findings should be interpreted along with some limitations. First, our focus on personality, measured at middle or older age, raises concerns about the potential evolution of personality traits over time. Future research should explore personality throughout the entire lifespan, considering that personality characteristics in early or midlife may hold relevance in shaping the trajectory of health behaviors and chronic conditions, such as chronic pain. We also only examined conscientiousness, among the Big Five personality traits. Other traits, such as neuroticism, are associated with depressive symptoms among those with pain (Ibrahim et al., 2020), but data on these other traits are not collected in the MHAS. Our study offers an initial step toward understanding these complex dynamics, but future comprehensive and longitudinal work is needed to further unpack the interplay between personality and mental health across diverse aging contexts. Additionally, while the possibility of reverse causality—where pain may influence both LOC and personality—is recognized, further research is needed to better understand this relationship. Prior work has found that personality traits can influence how people develop and adjust to pain (Naylor, Boag, & Gustin, 2017). However, previous work has found that although modifiable, locus of control and conscientiousness are relatively stable (Anderson, Cochrane, Golding, & Nowicki, 2018; Lucas & Donnellan, 2011; Specht, Egloff, & Schmukle, 2011). Given that depressive symptoms were assessed at only two discrete survey time points, our ability to capture fluctuations between waves is limited, which could lead to a potential underestimation of the associations reported. Future studies should evaluate changes in depression at a finer scale (e.g., month to month) to better characterize how personality influences depressive symptoms over time. Lastly, this study did not characterize pain location or consider that those with chronic pain may not have access to care or medications to resolve their pain due to data limitations. However, it is important to note that in Mexico, the public insurance program is widely utilized by older adults, making it less likely that differential access to healthcare services influenced our findings. Additionally, we adjusted for relevant socioeconomic covariates that may pattern healthcare utilization and quality. However, study strengths include a well-characterized sample, the use of multiple waves of data, and the utilization of a depressive symptoms battery, which has been clinically validated in Mexican adults. Studying this data set both cross-sectionally and longitudinally allowed for the evaluation of both acute and chronic pain.

Conclusions

In our sample of middle-aged and older community-dwelling Mexicans with pain, a more internal LOC was protective against recurrently high depressive symptoms, while a more conscientious personality was protective against recent-onset and recurrently high depressive symptoms. Interventions to modify LOC and conscientiousness, including psychoeducational approaches and cognitive behavioral therapy, may be helpful in alleviating depressive symptoms among middle-aged and older adults with pain.

Supplementary Material

Supplemental Materials

Table 4:

Adjusted relative risk ratios and 95% confidence intervals for the association between personality in 2015 (locus of control and conscientiousness) and changes in depressive symptoms (ref: stable no/low depressive symptoms) among participants (aged 50+) of the Mexican Health and Aging Study (MHAS) with persistent pain (2015 and 2018) (n=2,274).

Recently Remitted Recent-Onset Recurrently High
RRR (95% CI) P- value RRR (95% CI) P- value RRR (95% CI) P-Value
Model 1: Unadjusted
Personality Traits
Locus of Control 0.77 (0.68, 0.88) <0.001 0.86 (0.76, 0.99) 0.031 0.70 (0.63, 0.79) <0.001
Conscientiousness 0.88 (0.77, 0.999) 0.049 0.85 (0.75, 0.97) 0.015 0.84 (0.75, 0.93) 0.001
Model 2: Demographic Characteristics
Personality Traits
Locus of Control 0.90 (0.78, 1.04) 0.169 0.96 (0.83, 1.11) 0.585 0.83 (0.74, 0.93) 0.001
Conscientiousness 0.89 (0.77, 1.02) 0.095 0.86 (0.75, 0.99) 0.032 0.86 (0.77, 0.96) 0.008
Age 1.02 (1.001, 1.03) 0.041 1.01 (0.99, 1.03) 0.242 1.00 (0.99, 1.01) 0.961
Sex
Men ref. ref. ref.
Women 1.80 (1.33, 2.44) <0.001 1.44 (1.09, 1.92) 0.012 2.37 (1.85, 3.03) <0.001
Years of Education 0.95 (0.91, 0.98) 0.003 0.96 (0.93, 1.00) 0.034 0.94 (0.91, 0.96) <0.001
Marital Status
Single ref. ref. ref.
Married 0.63 (0.42, 0.93) 0.020 0.68 (0.46, 0.99) 0.043 0.67 (0.48, 0.93) 0.015
Widowed 0.77 (0.49, 1.24) 0.284 0.66 (0.41, 1.06) 0.088 0.79 (0.53, 1.17) 0.245
Health Insurance
No ref. ref. ref.
Yes 1.14 (0.67, 1.94) 0.623 1.00 (0.62, 1.62) 0.998 1.11 (0.73, 1.69) 0.634
Consumer Durables
0-3 ref. ref. ref.
4-6 0.79 (0.54, 1.15) 0.217 0.70 (0.48, 1.03) 0.067 0.63 (0.46, 0.85) 0.003
7+ 0.60 (0.38, 0.94) 0.024 0.73 (0.48, 1.13) 0.161 0.35 (0.24, 0.50) <0.001
Locality Size
Rural ref. ref. ref.
Urban 0.73 (0.55, 0.96) 0.027 0.67 (0.51, 0.88) 0.004 0.78 (0.62, 0.98) 0.032
Model 3: Demographic + Health Chararacteristics
Personality Traits
Locus of Control 0.90 (0.78, 1.04) 0.166 0.95 (0.83, 1.10) 0.508 0.81 (0.72, 0.92) 0.001
Conscientiousness 0.90 (0.78, 1.03) 0.128 0.87 (0.76, 0.998) 0.046 0.87 (0.77, 0.97) 0.013
Age 1.02 (1.00, 1.03) 0.065 1.01 (0.99, 1.02) 0.320 0.99 (0.98, 1.01) 0.396
Sex
Men ref. ref. ref.
Women 1.75 (1.29, 2.38) <0.001 1.38 (1.03, 1.84) 0.030 2.06 (1.59, 2.66) <0.001
Years of Education 0.95 (0.91, 0.98) 0.004 0.96 (0.93, 0.997) 0.036 0.94 (0.91, 0.97) <0.001
Marital Status
Single ref. ref. ref.
Married 0.65 (0.44, 0.96) 0.031 0.66 (0.45, 0.97) 0.035 0.69 (0.49, 0.95) 0.025
Widowed 0.81 (0.50, 1.30) 0.374 0.65 (0.40, 1.05) 0.081 0.82 (0.54, 1.23) 0.335
Health Insurance
No ref. ref. ref.
Yes 1.15 (0.67, 1.98) 0.606 1.00 (0.62, 1.61) 0.990 1.04 (0.67, 1.60) 0.859
Consumer Durables
0-3 ref. ref. ref.
4-6 0.80 (0.54, 1.17) 0.251 0.70 (0.48, 1.02) 0.063 0.63 (0.46, 0.87) 0.005
7+ 0.61 (0.39, 0.95) 0.030 0.73 (0.47, 1.13) 0.159 0.36 (0.25, 0.51) <0.001
Locality Size
Rural ref. ref. ref.
Urban 0.73 (0.55, 0.97) 0.032 0.66 (0.50, 0.88) 0.004 0.76 (0.60, 0.97) 0.025
Pain Severity
Mild ref. ref. ref.
Moderate 1.26 (0.92, 1.73) 0.155 1.13 (0.84, 1.51) 0.426 1.51 (1.16, 1.98) 0.003
Severe 1.32 (0.90, 1.94) 0.153 1.14 (0.79, 1.66) 0.483 2.12 (1.55, 2.91) <0.001
Pain Interferes with Daily Activities
No ref. ref. ref.
Yes 1.73 (1.31, 2.29) <0.001 1.01 (0.77, 1.32) 0.967 2.07 (1.65, 2.61) <0.001
Chronic Conditions
0 ref. ref. ref.
1 0.99 (0.70, 1.40) 0.946 0.97 (0.69, 1.36) 0.865 1.05 (0.77, 1.43) 0.758
2 or more 0.93 (0.66, 1.33) 0.701 1.19 (0.85, 1.67) 0.306 1.58 (1.17, 2.14) 0.003
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Note. Model 1 Pseudo R2=0.0106; Model 2 Pseudo R2=0.0428; Model 3 Pseudo R2= 0.0661.

Funding/acknowledgements:

This work was supported by the National Institute on Aging (NIA)/National Institutes of Health (NIH) (grant numbers P30AG024832, P30AG059301, K01AG075254, F31AG081071, T32AG049663) and the NIH/Office of the Director/National Institute of Allergy and Infectious Diseases/Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant number K12HD052023). The Mexican Health and Aging Study is supported by the NIA/NIH (R01AG018016; Wong, PI) in the United States and the National Institute of Statistics in Mexico. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Footnotes

Conflict of Interest: None

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